Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
--Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)

Thursday, January 25, 2007

I've never written a post to respond to one of my own posts before, but I think this time I have to. I have gotten enough "Clink is a heartless bastard" comments that I need to write, for the last time, that my post on the Retreat was a criticism of the service, not the patients. It got warped into an animated and a bit of an angry discussion about who I thought was or was not deserving of treatment---as if I my opinion about that actually mattered.

It's no revelation to state that America has a three-tiered healthcare caste system: the have-nots, the have-somethings (with insurance) and the boutique set. I work with the have-nots. My patients are poor. I don't mean poor in a "don't-have-insurance" sort of way. I mean poor in a "My family died in a house fire because they were using candles for heat and light" kind of way. The kind of poor who come in psychotic from the streets after living over sidewalk grates in the wintertime. The kind of poor who will die fast unless they get locked up.

So when I see a web site like the Retreat it's like getting a punch right between the old values. It's a visceral reaction, an "oh...my...gawd" kind of feeling that can't even come close to comparing with what my patients will never have. It's a sense that the cosmic balance of justice has gone far far out of whack and that we are in for an upheaval of our own making if we don't do something proactive to address the problem.

I am not stating that the boutique patients are undeserving of care. I am saying that we as a society need to make sure that all who need healthcare receive it. We as a society need to make these decisions. They cannot be left to bureaucrats or businessmen, or even solely to doctors and patients. We have all created this system and we must resolve it. Boutique medicine is not the solution.

To do this we will have to answer difficult questions about where to put our resources and how far to go with them. We will have to weigh the pros and cons of a fifty minute therapy session for non-psychotic patients versus two med check appointments for psychotic folks. People who are receiving treatment now may have to give a little to make room for those who are receiving none. I don't think that's too much to ask.

[Addendum: While I was working on this post I read on CNN that all the current Democratic candidates are in favor of universal healthcare coverage. A national health system is on the way. Hopefully Shrink Rap's posts will help us prepare for this by leading some discussion.]

8
comments:

It's not the same pot of money, in fact, one might contend that The Retreat, which takes no insurance and is a self-pay cash on entry deal, makes money for Sheppard Pratt (the parent hospital) and thus subsidizes the regular psychiatric hospital. So those folks are paying for the care of those who can't. If you got rid of The Retreat, this would not increase resources for your patient/inmates, I think it only works that way in Communist countries.

I am in favor of Universal coverage, the current system of government coverage is unfair and actually rather random. But, as we have with education or any other resource (cars, houses, food), this will only happen in this country if there is the choice to either opt out or pay for more. A system like Canada which dictates that one can not go outside the system will not work here.

The next time we go out for a nice dinner, I expect you to bring the leftovers back to the prisoners.

Dinah that's exactly what I said in my original post---in one of the comments, anyway. The only redeeming quality (IMHO) about the retreat is that it underwrites care for many others who don't go there. I don't think that's the most efficient way to provide care for the poor though.

I'm a Canadian, and I think that not being able to go outside the system is one of the best things about it. When the premier of Québec got flesh-eating disease and lost his leg, he went to a public hospital. Because there are no private hospitals. Of course he got a nice room to himself and private nursing care and his doctors made full use of video consults with US specialists - but it was a room in a public hospital, doctors who treat the public (that is, absolutely everyone) and bill the government (just think of the reduced paperwork! Yippee!) and videoconferencing facilities in a public hospital that are also available for the care of anyone else who needs it.

If the powers-that-be want to be able to access services in Canada, they need to make sure that those services are available to the powerless as well. It's all or nothing. You don't have one full-service hospital where the rich get what they want and another hospital that provides services "good enough" for the poor. (Well actually we do - but the divisions are rural vs urban, not public vs private; the state pays to transport patients from rural hospitals to urban ones when they need it.)

Of course the rich/powerful/famous get quicker/more intensive treatment than the rest of us - Canadians are human too - but it's in the same hospital with the same staff.

Reading Grunt Doc's and Charity Doc's ER blogs and the way they despise so many of their patients ("Get your entitled, uninsured ass out of my emergency room!") I'm really glad my doctors don't have to worry about which of their patients are uninsured and milking the system.

Grunt Doc, Charity Doc and Kevin MD also get all riled up about people who spend all day in the ER so they can get free meds because they can't afford to pay out of pocket; and they (our med bloggers) expend lots of energy judging these patients for being able to afford cigarettes but not meds for their kids. We even have universal drug insurance. So we get these dynamics out of the doctor-patient relationship as well.

Universal drug insurance, by the way, is what enabled me to get an expensive drug (Zoloft) that enabled me to go from years of chronic un/under employment to full, privately insured, tax-paying employment in less than ten months. So in my case at least, it was a terrific investment on the part of the governement.

I know there's lots of fear-mongering about Socialised Medicine in the US, but don't knock it till you've tried it. I don't know anyone who complains about their medical treatment or their insurance plans here; I know lots of people who do in the US (I have American relatives).

Oh - and RE having a parallel education system - I'm not sure how well that's working out in the US. In many areas parents opt out of the public system as soon as they are financially able because it simply isn't even minimally adequate. Meaning that people who vote don't have a stake in the public system, and meaning that the best teachers can be drained off into the private stream, the one that actually works.

To some extent, yes, it is a zero-sum game. When one of the limiting factors is a shortage of trained medical and nursing personnel, taking part of the limiting resource out of the common stream and dedicating it to people who don't necessarily need it as urgently but feel like getting their [hip replacement, cataract surgery] earlier does in fact make the public line longer. So yes, we need to take resource allocation into account.

Yes, we have both public and private education in Canada. I suspect we see some of the same effects that you do in the US, but perhaps not as dramatically. The horror stories I happen to hear are about US public education systems, not Canadian ones. But that could be for other reasons as well.

I just wanted to point out that the example of parallel streams in the education system make exactly the point about the risks/dangers of allowing opt-out. They don't at all show that it's a no-risk, no-brainer.

Off topic but I just wanted to say I know plenty of Canadians who've complained about their health system. Things like having to wait at least 8 months for a brain MRI. When it works well, it's wonderful. When it doesn't, not so good. Similarly within the NHS in the UK (where I'm from). A relative recently had fabulous treatment for a very serious health problem but I know of others who have been stuck in the system waiting for ages.

I agree with Dinah. I use my private health cover in public hospitals. This provides direct financial benefit to the public hospital system.

"Off topic but I just wanted to say I know plenty of Canadians who've complained about their health system. Things like having to wait at least 8 months for a brain MRI."

Aha, but you see these sound like two different propositions.

The Canadians I know personally (ranging from rude good health through severe physical disability through mild hypochondriasis, some poor, some pretty darn well off but all with middle-class educations) do not complain about the health care they personally receive. Neither do they complain about hassles getting coverage for it.

The Americans I know personally (similar range to above) do not complain about the health care they receive either, but they do complain about hassles getting coverage for it.

Journalists find problems with the systems on both sides of the border, and Canadians worry about their health system just as Americans worry about theirs. And yes, the Canadian system does have problems. Especially when we have governments with a philosophical bent in favour of privatisation who coincidentally happen to cut public funding. Then the shortcomings of our publicly funded system become easy to identify, and private funding is promoted as a solution.

Even without this sort of disingenuous tinkering, publicly funded systems will always have the problems of publicly funded systems, just as privately funded systems will always have the problems of privately funded systems. But being Canadian isn't nearly the dreary, helpless and unhelped experience that is often portrayed in the US. Really not.

My grandfather was a doctor in a depressed area of upstate NY. He was then and remains in favour of single-payer insurance. His son, my uncle, is a doctor too, but in a better-off urban area. My uncle sees no need for single-payer, and no need for any American to be denied essential medical treatment for financial reasons. "If you can't afford cancer treatment, then all you need to do is declare bankruptcy." This might make sense to Americans, but the Canadians in the room were appalled that the idea of having to declare bankruptcy in order to access medical care could be so cavalierly accepted. We, um, don't ask people to do that.